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Prior authorization · Outsourcing
Outsource prior authorization to a team that does it every day for oncology, behavioral health, neurology, rheumatology and surgical practices. We check whether each service needs approval, submit with the right clinicals, track every request to a decision, and record the authorization on the claim so it never comes back as a CO-197 denial.
Illustrative example with sample data
The basics
Prior authorization, also called pre-authorization or precertification, is a health plan's requirement to approve a service, procedure or drug before it is provided, or the plan may refuse to pay. Prior authorization services take that work off your staff: checking whether approval is needed, gathering the clinical documentation, submitting the request by portal, electronic prior authorization, fax or phone, following up until a decision, handling peer-to-peer reviews and appeals, and recording the approval so the claim is paid.
| In-house staff | PhysiAssist prior authorization team | |
|---|---|---|
| Coverage | Depends on one or two people; requests wait when they are out | A team with trained backups for every client and payer |
| Payer rules | Each person tracks the payers they know | Requirements tracked centrally by payer, benefit manager and service |
| Follow-up | When there is time between calls and check-ins | Status checks scheduled against each payer's deadline, by our voice agent and staff |
| Visibility | Spreadsheets, sticky notes or the EHR inbox | Every request live in RevCore by status, payer, service and days open |
| Cost | Salary, benefits, training and turnover | Quoted with your proposal, separate from the 2.8% to 5% billing rate |
In-house works well for a small number of predictable payers. Outsourcing pays off when volume, payer mix or staff turnover makes requests wait.
Turnaround
It depends on the plan and the urgency. Since January 1, 2026, Medicare Advantage plans, Medicaid and CHIP programs, and ACA marketplace plans on the federal exchange must decide standard requests within 7 calendar days and expedited requests within 72 hours, under the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Commercial employer plans follow their contracts and state law, and some states now set shorter clocks. The longest delays usually happen before the clock starts: missing clinicals, the wrong form, or a request sent to the wrong benefit manager.
Expedited requestCMS-0057-F plans
Standard requestCMS-0057-F plans
Indiana, state-regulated plansSB 480 (2025)
Iowa, state-regulated plansHF 303 (2025)
Bars show the standard or non-urgent limit on a 10-day scale. Summaries for orientation, not legal advice. Self-funded employer plans generally fall under federal law rather than state insurance rules.
Your numbers
Defaults follow the AMA 2025 survey: 40 requests and about 13 hours per physician each week.
Prior authorizations a month
1,386
Physicians × weekly requests × 4.33
Staff hours a month
462
Requests × minutes, before follow-up calls
Full-time staff equivalent
2.9
At 160 working hours a month
Our process
Six steps, each with an owner and a timestamp your team can see.
Every scheduled service is checked against the plan's current authorization list and the benefit manager that reviews it, such as eviCore or Carelon for imaging.
Notes, imaging, labs, the treatment plan and prior therapies, matched to the payer's written criteria before anything is sent.
By portal, electronic prior authorization, fax or phone, whichever the payer requires, logged with a reference number.
Status checks timed to the payer's deadline, by our voice agent and our team. A pending request never waits unseen.
Peer-to-peer reviews scheduled for your physician, expedited requests when care is urgent, and appeals when a request is denied.
The auth number, approved codes, units and dates are saved to the patient and flow to the claim. Renewals are flagged before they lapse.
By specialty
Each specialty has its own high-cost services and its own payer criteria. Our authorization specialists work by specialty, so they know what each payer will ask for.
Federal and state rules
Prior authorization rules changed more in 2025 and 2026 than in the decade before. We track federal rules and state laws for each plan type, so every request is held to the right deadline.
| Rule | Applies to | What it means for your requests |
|---|---|---|
| CMS-0057-F Federal, from Jan 1, 2026 | Medicare Advantage, Medicaid and CHIP, ACA plans on the federal exchange | Decisions within 72 hours (expedited) or 7 calendar days (standard), a specific reason for every denial, published approval metrics, and a standard electronic prior authorization API by January 1, 2027. |
| Texas gold-card law HB 3459, amended by HB 3812 (2025) | State-regulated plans | Physicians with high approval rates for a service are exempt from prior authorization for it. The 2025 change lengthened the review period from six months to one year. |
| West Virginia gold carding Amended by SB 833 (2025) | State-regulated plans | A gold-card program is in place; the 2025 amendment removed medication prescribing from it. |
| Washington SB 5395 Signed 2026 | State-regulated plans | Denials cannot be made by AI alone; a licensed practitioner must decide. Plans must post policy updates in one place. A 2023 state law requires prior authorization inside the EHR from January 1, 2027. |
| Indiana SB 480 2025 | State-regulated plans | Reviews within 24 hours (urgent) or 48 hours (non-urgent), and new plans must honor an existing authorization for at least 90 days. |
| Iowa HF 303 2025 | State-regulated plans | Decisions within 48 hours (urgent) or 10 calendar days (non-urgent), with annual reporting. |
Summaries for orientation, not legal advice. Self-funded employer plans generally follow federal law rather than state insurance rules. Sources: CMS Interoperability and Prior Authorization Final Rule; state legislature records; MultiState; Washington State Medical Association.
Our AI products
Our team uses these tools on every request. You can also license them for your own staff.
Call payers for authorization status on a schedule and log the answer, the reference number and the next step on the request.
For oncology: checks every cycle of a regimen against the authorization on file, with drug codes and units, and flags renewals before they run out.
Every request in one live tracker shared by your team and ours: status, payer, days open, owner and the authorization details that flow to the claim.
Checking whether each scheduled service needs approval, collecting the clinical documentation the payer requires, submitting the request, following up until a decision, arranging peer-to-peer reviews and appeals, and recording the approved codes, units and dates so the claim is paid.
Since January 1, 2026, Medicare Advantage, Medicaid and CHIP, and ACA marketplace plans on the federal exchange must decide within 7 calendar days for standard requests and 72 hours for expedited requests. Commercial plans follow their contracts and state law. Complete clinicals at submission are the biggest factor in how fast a decision comes.
Outsourcing makes sense when requests wait because staff are out, payer rules are hard to keep current, or volume keeps growing. An outsourced team brings backups, central tracking of payer rules and scheduled follow-up. In-house can work for a small number of predictable payers.
It is the CMS Interoperability and Prior Authorization Final Rule. From January 1, 2026, covered plans must decide within 72 hours for expedited and 7 calendar days for standard requests, give a specific reason for every denial and publish prior authorization metrics. By January 1, 2027, they must offer a standard electronic prior authorization API. It covers Medicare Advantage, Medicaid and CHIP, and ACA plans on the federal exchange, not traditional Medicare or most employer plans.
We read the denial reason, which covered plans must now state specifically, and choose the fastest route: send missing records, schedule a peer-to-peer review with your physician, or file an appeal with the clinical criteria the request meets.
Some payers allow a retroactive authorization within a set window, often for urgent care; many do not. We check each payer's policy and request one where it is allowed. The better fix is a check at scheduling, so a retro request is rarely needed.
Yes, for drugs your practice administers and bills, such as chemotherapy, immunotherapy, biologics and other infusions, including step-therapy documentation and renewals.
Prior authorization is quoted separately from the 2.8% to 5% billing rate. We quote it in writing after reviewing your authorization volume and payer mix, whether you add it to full billing or use it on its own.
A 30-minute call with a prior authorization specialist in your field, using your payers and your services.